Pulsed Red and Blue Photobiomodulation for the Treatment of Thigh Contusions and Soft Tissue Injury: A Randomized Controlled Trial.

CONTEXT: Contusion and soft tissue injuries are common in sports. Photobiomodultion, light and laser therapy, is an effective aid to increase healing rates and improve function after various injury mechanisms. However, it is unclear how well photobiomodulation improves function after a contusion soft tissue injury. This study aimed to determine the effects of a pulsed red and blue photobiomodulation light patch on muscle function following a human thigh contusion injury. DESIGN: Single-blinded randomized control trial design. METHODS: We enrolled 46 healthy participants. Participants completed 5 visits on consecutive days. On the first visit, participants completed a baseline isokinetic quadriceps strength testing protocol at 60°/s and 180°/s. On the second visit, participants were struck in the rectus femoris of the anterior thigh with a tennis ball from a serving machine. Immediately following, participants were treated for 30 minutes with an active or placebo photobiomodulation patch (CareWear light patch system, CareWear Corp). Following the treatment, participants completed the same isokinetic quadriceps strength testing protocol. Participants completed the treatment and isokinetic quadriceps strength test during the following daily visits. We normalized the data by calculating the percent change from baseline. We used a mixed model analysis of covariance, with sex as a covariate, to determine the difference between treatment groups throughout the acute recovery process. RESULTS: We found the active photobiomodulation treatment significantly increased over the placebo group, quadriceps peak torque during the 180°/s test (P = .030), and average power during both the 60°/s (P = .041) and 180°/s (P ≤ .001) assessments. The mean peak torque and average power of 180°/s, at day 4, exceeded the baseline levels by 8.9% and 16.8%, respectively. CONCLUSIONS: The red and blue photobiomodulation light patch improved muscle strength and power during the acute healing phase of a human thigh contusion injury model.

Efficacy of Sustained Acoustic Medicine as an Add-on to Traditional Therapy in Treating Sport-related Injuries : Case Reports.

CONTEXT: Musculoskeletal injuries are prevalent in sports, and the application of Sustain Acoustic Medicine (SAM) as a home-use add-on therapy to reduce pain and to increase the probability of athletes returning to sports was evaluated in a case series. OBJECTIVES: To examine the improvements in pain and return to function of athletes using SAM in conjunction with traditional therapies after sustaining sports-related musculoskeletal injuries. INTRODUCTION: Traditional treatments such as rest, physical therapy, manual therapy, a combination of rest, ice compression, and elevation (RICE) are standard of care for musculoskeletal injuries and do not provide adequate accelerated healing to return athletes to activity. SAM is an FDA-approved bio-regenerative technology, which can provide mechanotransductive and thermal stimuli to accelerate tissue healing and reduction in pain daily. Interventions: A case series of 18 athletes who showed little or no improvement with traditional therapies where prescribed SAM treatment as an add-on daily home-use intervention. The study included athletes with sports musculoskeletal injuries, including the arm/shoulder, upper leg/glutes/hips, knees, back, and foot/ankle. Clinical outcomes were recorded along with the ability of athletes' ability to go back to sports, and satisfaction and usability measures of the home treatment. Results: All athletes were satisfied with the usability and comfort of the therapy and 93%reported the therapy was sufficiently discrete. Clinical outcomes indicate all athletes showed an average pain decrease of 3.33±0.82 (p≤0.05) numerical rating scales (NRS), improvement in function, and quality of life. 87% of the athletes documented an improvement in function, and 55% were able to return to sports after conservative intervention failed. Conclusion: The results of this study indicate that SAM improves athletes' clinical outcomes. Over 50% of athletes were able to return to sports and resume normal daily function after conservative intervention had failed with addition of daily SAM treatment.

Kant, Linnaeus, and the economy of nature.

Ecology arguably has roots in eighteenth-century natural histories, such as Linnaeus's economy of nature, which pressed a case for holistic and final-causal explanations of organisms in terms of what we'd now call their environment. After sketching Kant's arguments for the indispensability of final-causal explanation merely in the case of individual organisms, and considering the Linnaean alternative, this paper examines Kant's critical response to Linnaean ideas. I argue that Kant does not explicitly reject Linnaeus's holism. But he maintains that the indispensability of final-causal explanation depends on robust modal connections between types of organism and their functional parts; relationships in Linnaeus's economy of nature, by contrast, are relatively contingent. Kant's framework avoids strong metaphysical assumptions, is responsive to empirical evidence, and can be fruitfully compared with some contemporary approaches to biological organization.

The well-being valuation model: a method for monetizing the nonmarket good of individual well-being.

The objective of this research is to advance the evaluation and monetization of well-being improvement programs, offered by population health management companies, by presenting a novel method that robustly monetizes the entirety of well-being improvement within a population. This was achieved by utilizing two employers' well-being assessments with medical and pharmacy administrative claims (2010-2011) across a large national employer (n = 50,647) and regional employer (n = 6170) data sets. This retrospective study sought to monetize both direct and indirect value of well-being improvement across a population whose medical costs are covered by an employer, insurer, and/or government entity. Logistic regression models were employed to estimate disease incidence rates and input-output modelling was used to measure indirect effects of well-being improvement. These methodological components removed the burden of specifying an exhaustive number of regression models, which would be difficult in small populations. Members who improved their well-being were less likely to become diseased. This reduction saved, per avoided occurrence, US$3060 of total annual health care costs. Of the members who were diseased, improvement in well-being equated to annual savings of US$62 while non-diseased members saved US$26. The method established here demonstrates the linkage between improved well-being and improved outcomes while maintaining applicability in varying populations.

What's Mine is Yours: Evaluation of Shared Well-Being Among Married Couples and the Dyadic Influence on Individual Well-Being Change.

OBJECTIVE: To evaluate the relationship between partner well-being and outcomes of chronically diseased individuals participating in an employer sponsored well-being improvement program. METHODS: Using the Actor Partner Interdependence Model, we evaluated whether prior partner well-being was associated with well-being change among 2025 couples. Logistic regression models were then used to explore how spousal well-being risks relate to development and elimination of risks among program participants. RESULTS: High well-being partners were associated with positive well-being change. Specifically, the partner effect for spouses' high well-being on disease management participants was a 1.5 point higher well-being in the following time period (P = 0.001) while the partner effect of participants' high well-being on spouses was nearly 1.1 points (P = 0.010). CONCLUSIONS: Well-being within couples is interdependent, and partner well-being is an important predictor of individual well-being change.

Integrating Well-Being Information and the Multidimensional Adaptive Prediction Process to Estimate Individual-Level Future Health Care Expenditure Levels.

Decades of research exist focusing on the utility of self-reported health risk and status data in health care cost predictive models. However, in many of these studies a limited number of self-reported measures were considered. Compounding this issue, prior research evaluated models specified with a single covariate vector and distribution. In this study, the authors incorporate well-being data into the Multidimensional Adaptive Prediction Process (MAPP) and then use a simulation analysis to highlight the value of these findings for future cost mitigation. Data were collected on employees and dependents of a nationally based employer over 36 months beginning in January 2010. The first 2 years of data (2010, 2011) were utilized in model development and selection; 51239 and 54085 members were included in 2010 and 2011, respectively. The final results were based on prospective prediction of 2012 cost levels using 2011 data. The well-being-augmented MAPP results showed a 5.7% and 13% improvement in accurate cost capture relative to a reference modeling approach and the first study of MAPP, respectively. The simulation analysis results demonstrated that reduced well-being risk across a population can help mitigate the expected upward cost trend. This research advances health care cost predictive modeling by incorporating well-being information within MAPP and then leveraging the results in a simulation analysis of well-being improvement.

Impact of a scalable care transitions program for readmission avoidance.

OBJECTIVES: To evaluate the Care Transition Solution (CTS) as a means to improve quality through reduction of preventable hospital readmissions among patients with readmission-sensitive conditions subject to penalties imposed by the Affordable Care Act. STUDY DESIGN: A retrospective quasi-experimental evaluation of the impact of the CTS among admitted patients diagnosed with heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and/or pneumonia (CMS readmission-penalty diagnoses) in 14 acute care hospitals in Texas. The program, designed for scalable delivery, incorporated identification of high readmission-risk patients, assessment of individual needs, medication reconciliation, discharge planning, care coordination, and telephonic postdischarge follow-up. METHODS: The treatment group of program enrollees (N = 560) and the comparison group with no program contact (N = 3340) were matched on 8 coarsened demographic, diagnosis, and severity variables associated with readmission risk. Assessed outcomes included relative risk and odds of readmission within 30 days postdischarge and overall within the 6-month evaluation period. Zero-inflated Poisson multivariate models were used to estimate intervention effects controlling for matching-generated weights, age, disease status, and period of evaluation. RESULTS: Treatment group risk of readmission was 22% lower overall (incidence rate ratio [IRR], 0.78; P < .01) and 30-day readmission risk was 25% lower (IRR, 0.75; P = .01) relative to the comparison group. Odds of any or 30-day readmission were 0.47 (95% CI, 0.35-0.65) and 0.56 (95% CI, 0.41-0.77), respectively, for treatment relative to comparison. CONCLUSIONS: Participation in the CTS resulted in significantly lower rates of readmissions among patients with readmission-sensitive conditions, offering a scalable and sustainable approach to reduce the number of preventable hospital readmissions.

The Value of a Well-Being Improvement Strategy: Longitudinal Success across Subjective and Objective Measures Observed in a Firm Adopting a Consumer-Driven Health Plan.

OBJECTIVE: The objective of this study is to evaluate effectiveness of a firm's 5-year strategy toward improving well-being while lowering health care costs amidst adoption of a Consumer-Driven Health Plan. METHODS: Repeated measures statistical models were employed to test and quantify association between key demographic factors, employment type, year, individual well-being, and outcomes of health care costs, obesity, smoking, absence, and performance. RESULTS: Average individual well-being trended upward by 13.5% over 5 years, monthly allowed amount health care costs declined 5.2% on average per person per year, and obesity and smoking rates declined by 4.8 and 9.7%, respectively, on average each year. The results show that individual well-being was significantly associated with each outcome and in the expected direction. CONCLUSIONS: The firm's strategy was successful in driving statistically significant, longitudinal well-being, biometric and productivity improvements, and health care cost reduction.

Predicting Health Care Cost Transitions Using a Multidimensional Adaptive Prediction Process.

Managing population health requires meeting individual care needs while striving for increased efficiency and quality of care. Predictive models can integrate diverse data to provide objective assessment of individual prospective risk to identify individuals requiring more intensive health management in the present. The purpose of this research was to develop and test a predictive modeling approach, Multidimensional Adaptive Prediction Process (MAPP). MAPP is predicated on dividing the population into cost cohorts and then utilizing a collection of models and covariates to optimize future cost prediction for individuals in each cohort. MAPP was tested on 3 years of administrative health care claims starting in 2009 for health plan members (average n=25,143) with evidence of coronary heart disease. A "status quo" reference modeling methodology applied to the total annual population was established for comparative purposes. Results showed that members identified by MAPP contributed $7.9 million and $9.7 million more in 2011 health care costs than the reference model for cohorts increasing in cost or remaining high cost, respectively. Across all cohorts, the additional accurate cost capture of MAPP translated to an annual difference of $1882 per member, a 21% improvement, relative to the reference model. The results demonstrate that improved future cost prediction is achievable using a novel adaptive multiple model approach. Through accurate prospective identification of individuals whose costs are expected to increase, MAPP can help health care entities achieve efficient resource allocation while improving care quality for emergent need individuals who are intermixed among a diverse set of health care consumers.

Regional economic activity and absenteeism: a new approach to estimating the indirect costs of employee productivity loss.

This paper presents a new approach to estimating the indirect costs of health-related absenteeism. Productivity losses related to employee absenteeism have negative business implications for employers and these losses effectively deprive the business of an expected level of employee labor. The approach herein quantifies absenteeism cost using an output per labor hour-based method and extends employer-level results to the region. This new approach was applied to the employed population of 3 health insurance carriers. The economic cost of absenteeism was estimated to be $6.8 million, $0.8 million, and $0.7 million on average for the 3 employers; regional losses were roughly twice the magnitude of employer-specific losses. The new approach suggests that costs related to absenteeism for high output per labor hour industries exceed similar estimates derived from application of the human capital approach. The materially higher costs under the new approach emphasize the importance of accurately estimating productivity losses.

Comparing the contributions of well-being and disease status to employee productivity.

OBJECTIVE: To compare employee overall well-being to chronic disease status, which has a long-established relationship to productivity, as relative contributors to on-the-job productivity. METHODS: Data from two annual surveys of three companies were used in longitudinal analyses of well-being as a predictor of productivity level and productivity change among 2629 employees with diabetes or without any chronic conditions. RESULTS: Well-being was the most significant predictor of productivity cross-sectionally in a model that included disease status and demographic characteristics. Longitudinally, changes in well-being contributed to changes in productivity above and beyond what could be explained by the presence of chronic disease or other fixed characteristics. CONCLUSIONS: These findings support the use of well-being as the broader framework for understanding, explaining, and improving employee productivity in both the healthy and those with disease.

Exploring robust methods for evaluating treatment and comparison groups in chronic care management programs.

Evaluation of chronic care management (CCM) programs is necessary to determine the behavioral, clinical, and financial value of the programs. Financial outcomes of members who are exposed to interventions (treatment group) typically are compared to those not exposed (comparison group) in a quasi-experimental study design. However, because member assignment is not randomized, outcomes reported from these designs may be biased or inefficient if study groups are not comparable or balanced prior to analysis. Two matching techniques used to achieve balanced groups are Propensity Score Matching (PSM) and Coarsened Exact Matching (CEM). Unlike PSM, CEM has been shown to yield estimates of causal (program) effects that are lowest in variance and bias for any given sample size. The objective of this case study was to provide a comprehensive comparison of these 2 matching methods within an evaluation of a CCM program administered to a large health plan during a 2-year time period. Descriptive and statistical methods were used to assess the level of balance between comparison and treatment members pre matching. Compared with PSM, CEM retained more members, achieved better balance between matched members, and resulted in a statistically insignificant Wald test statistic for group aggregation. In terms of program performance, the results showed an overall higher medical cost savings among treatment members matched using CEM compared with those matched using PSM (-$25.57 versus -$19.78, respectively). Collectively, the results suggest CEM is a viable alternative, if not the most appropriate matching method, to apply when evaluating CCM program performance.

Impact of a chronic disease management program on hospital admissions and readmissions in an Australian population with heart disease or diabetes.

Chronic disease management programs (CDMPs) were introduced in Australia to reduce unnecessary health care utilization by the growing population with chronic conditions; however, evidence of effectiveness is needed. This study evaluated the impact of a comprehensive CDMP, My Health Guardian (MHG), on rate of hospital admissions, readmissions, and average length of hospital stay (ALOS) for insured individuals with heart disease or diabetes. Primary outcomes were assessed through retrospective comparison of members in MHG (treatment; n=5053) to similar nonparticipating members (comparison; n=23,077) using a difference-in-differences approach with the year before program commencement serving as baseline and the subsequent 12 or 18 months serving as the program periods. All outcomes were evaluated for the total study population and for disease-matched subgroups (heart disease and diabetes). Statistical tests were performed using multivariate regression controlling for age, sex, number of chronic diseases, and past hospitalization status. After both 12 and 18 months, treatment members displayed decreases in admissions (both, P≤0.001) and readmissions (both, P≤0.01), and ALOS after 18 months (P≤0.01) versus the comparison group; magnitude of impact increased over time for these 3 measures. All outcomes for both disease-matched subgroups directionally mirrored the total study group, but the diabetes subgroup did not achieve significance for readmissions or ALOS. Within the treatment group, admissions decreased with increasing care calls to members (12 and 18 months, P<0.0001). These results show that MHG successfully reduced the frequency and duration of hospital admissions and presents a promising approach to reduce the burden associated with hospitalizations in populations with chronic disease.

Avoiding randomization failure in program evaluation, with application to the Medicare Health Support program.

We highlight common problems in the application of random treatment assignment in large-scale program evaluation. Random assignment is the defining feature of modern experimental design, yet errors in design, implementation, and analysis often result in real-world applications not benefiting from its advantages. The errors discussed here cover the control of variability, levels of randomization, size of treatment arms, and power to detect causal effects, as well as the many problems that commonly lead to post-treatment bias. We illustrate these issues by identifying numerous serious errors in the Medicare Health Support evaluation and offering recommendations to improve the design and analysis of this and other large-scale randomized experiments.

The impact of proactive chronic care management on hospital admissions in a German senior population.

An increase in chronic disease prevalence is contributing to health care cost growth and decreased quality of life in industrialized nations worldwide. Inadequate management of chronic diseases is a leading cause of hospitalizations and, thus, avoidable expenditures. In this study, we evaluated the impact of nurse-delivered care calls, the primary intervention of a proactive chronic care management (CCM) program, in a population aged 65 and older in Germany. In this analysis, hospital admission rates were evaluated among program enrollees who were diagnosed with diabetes, heart failure, coronary heart disease, or chronic obstructive pulmonary disease. The Intervention group comprised those members who participated in care calls (n=13,486), whereas the Comparison group included enrollees who did not participate in these calls (n=4,582). Changes in admission rates were calculated between the year prior to and year after program commencement. Comparative analyses were adjusted for age, sex, region of residence, and disease severity (stratification of 3 [least severe] to 1 [most severe]). Overall, a 6.0% decrease in admissions was observed among Intervention group members compared with an 18.9% increase among Comparison group members (P ≤ 0.0001). This decrease in admissions was driven by participants with the highest levels of risk. In addition, a dose-response relationship was observed in which admissions decreased with an increased number of care calls (P=0.0001). These results indicate that proactive CCM interventions are effective in reducing hospital admission rates in a senior population with chronic disease.

Probing dimer interface stabilization within a four-helix bundle of the GrpE protein from Escherichia coli via internal deletion mutants: conversion of a dimer to monomer.

Insight into protein stability and folding remains an important area for protein research, in particular protein-protein interactions and the self-assembly of homodimers. The GrpE protein from Escherichia coli is a homodimer with a four-helix bundle at the dimer interface. Each monomer contributes a helix-loop-helix to the bundle. To probe the interface stabilization requirements, in terms of the amount of buried residues in the bundle necessary for dimer formation, internal deletion mutants (IDMs) were created that sequentially truncate each of the two helices in the helix-loop-helix region. Circular dichroism (CD) spectroscopy showed that all IDM's still contained a significant amount of α-helical secondary structure. IDM's that contained 11 or fewer of 22 residues originally present in the helices, or those that lost at least 50% of residues with less than 20% the solvent accessible surfaces (that is, hydrophobic residues) were unable to form a significant amount of dimer species as shown by chemical cross-linking. Gel filtration studies of IDM3.0 (one that retains 10 residues in each helix) show this variant to be mainly monomeric.

The impact of a proactive chronic care management program on hospital admission rates in a German health insurance society.

Hospital admissions are the source of significant health care expenses, although a large proportion of these admissions can be avoided through proper management of chronic disease. In the present study, we evaluate the impact of a proactive chronic care management program for members of a German insurance society who suffer from chronic disease. Specifically, we tested the impact of nurse-delivered care calls on hospital admission rates. Study participants were insured individuals with coronary artery disease, heart failure, diabetes, or chronic obstructive pulmonary disease who consented to participate in the chronic care management program. Intervention (n = 17,319) and Comparison (n = 5668) groups were defined based on records of participating (or not participating) in telephonic interactions. Changes in admission rates were calculated from the year prior to (Base) and year after program commencement. Comparative analyses were adjusted for age, sex, region of residence, and disease severity (stratification of 3 [least severe] to 1 [most severe]). Overall, the admission rate in the Intervention group decreased by 6.2% compared with a 14.9% increase in the Comparison group (P < 0.001). The overall decrease in admissions for the Intervention group was driven by risk stratification levels 2 and 1, for which admissions decreased by 8.2% and 14.2% compared to Comparison group increases of 12.1% and 7.9%, respectively. Additionally, Intervention group admissions decreased as the number of calls increased (P = 0.004), indicating a dose-response relationship. These findings indicate that proactive chronic care management care calls can help reduce hospital admissions among German health insurance members with chronic disease.

Increased adherence to cardiac standards of care during participation in cardiac disease management programs.

Adherence to cardiovascular disease standards of care is critically important for minimizing the risk of mortality and morbidity for individuals with coronary heart disease (CHD) and heart failure (HF). The purpose of this study was to assess the ability of cardiac disease management (DM) programs to assist members with their adherence to evidence-based medicine for cardiovascular diseases. A total of 20,202 members with CHD and/or HF were evaluated 12 months prior to the start of DM programs and during their first 12 months of participation in the programs. Members were assessed for their adherence to appropriate cardiac medications. In addition, low-density lipoprotein (LDL) testing rates and clinical control of LDL values (defined as <100 mg/dL) were measured. The association between LDL control and use of lipid-lowering statins also was assessed. During participation in the cardiac programs, members achieved significant improvement in their adherence to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers (P < 0.0001). The cardiac population also achieved a significant increase in LDL testing rates and statin use (P < 0.0001). More members attained appropriate LDL control in year 1 compared to baseline (36% relative increase), and this improvement was associated with a 40% relative increase in statin use. In summary, participation in these cardiac DM programs assisted members to improve their adherence to cardiac medications and standards of care guidelines. Such improvements in cardiovascular disease care are likely associated with improved quality of life and reduced risk for mortality.

Aaron O. Wells, MD and the Medical Committee for Human Rights: reflections on a life of conscience.

The southern civil rights movement compelled Dr. Aaron Wells and other doctors to find ways to use their skills in support of that movement. Through the Medical Committee for Human Rights (MCHR), healthcare workers provided a medical presence for civil rights protesters in the south during the 1960s. Formed at a time when racial segregation in professional medical associations, hospitals, and medical education was common, the MCHR also highlighted race-based inequities in American medicine. Dr. Wells, a man who lives a life of activism, was the first national president of the MCHR. During the summer of 2002, nearly 40 years after the founding of MCHR, Wells was interviewed about his experiences. Those reminiscences are the basis of this article.